The practical nurse (PN) observes that an unlicensed assistive personnel (UAP) is preparing to disconnect a client's IV tubing to remove the client's hospital gown during a bed bath. Which action should the PN implement?
Remind the UAP to clean the ends of the tubing with an alcohol swab.
Help the UAP disconnect the IV tubing to ensure sterility.
Obtain a hospital gown with snap sleeves to put on the client.
Demonstrate how to remove the client's gown without disconnecting the IV.
The Correct Answer is D
A. Remind the UAP to clean the ends of the tubing with an alcohol swab: While proper aseptic technique is important, disconnecting the IV unnecessarily increases the risk of infection. Prevention by proper gown removal technique is preferred.
B. Help the UAP disconnect the IV tubing to ensure sterility: Disconnecting the IV exposes the line to contamination and is unnecessary for a bed bath. This action increases infection risk and is not the recommended approach.
C. Obtain a hospital gown with snap sleeves to put on the client: Snap-sleeve gowns can help prevent IV disconnection, but the PN must first ensure the UAP understands proper technique for gown removal without disrupting the IV.
D. Demonstrate how to remove the client's gown without disconnecting the IV: Teaching the UAP the correct method prevents accidental disconnection, maintains aseptic technique, and ensures client safety. This addresses the issue directly and promotes safe practice.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Clonidine: Clonidine, an alpha-2 agonist, can cause side effects such as drowsiness, dry mouth, and rebound hypertension if discontinued abruptly. A persistent dry cough is not commonly associated with clonidine.
B. Quinapril: Quinapril is an ACE inhibitor, and a persistent dry cough is a well-known side effect due to accumulation of bradykinin in the respiratory tract. Clients taking ACE inhibitors should be monitored for this symptom, which may necessitate medication adjustment.
C. Spironolactone: Spironolactone is a potassium-sparing diuretic. Common side effects include hyperkalemia, gynecomastia, and menstrual irregularities, but it is not typically associated with a persistent dry cough.
D. Losartan: Losartan is an angiotensin receptor blocker (ARB) and generally does not cause cough. It is often prescribed as an alternative to ACE inhibitors for clients who experience cough.
Correct Answer is B,C,A,D
Explanation
A. Evaluate the UAP for signs of improvement: Following the teaching and feedback, the PN should observe the UAP’s future care interactions to ensure that the behavior has improved and that client privacy is consistently maintained.
B. Cover the client to provide privacy during care: The first priority is to protect the client’s dignity and privacy immediately. Ensuring the client is covered prevents further embarrassment and maintains ethical nursing standards.
C. Discuss the issue privately with the UAP: After addressing the client’s immediate needs, the PN should privately discuss the observed behavior with the UAP to promote learning and prevent public criticism, which can be unprofessional and counterproductive.
D. Report patterns of behavior to the supervisor: If the UAP repeatedly fails to uphold privacy standards despite feedback and monitoring, the PN must report the ongoing issue to the supervisor for further evaluation and possible corrective action.
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